Two ECGs texted to me in the same hour. What would you recommend?

Written by Pendell Meyers

Both of these cases were sent to me with no information other than adults with acute chest pain. What would be your response?

Case 1:

Case 2:

What if I told you that Case 1 has an abnormal initial troponin, and Case 2 has a normal initial troponin? 

Case 1

An elderly male presented with chest pain. His vitals were within normal limits except some mild hypertension. 

Here was his triage ECG:

What do you think?

I texted back: "I just see LVH with no signs of OMI".

I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict:

You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: https://bit.ly/omi-queen-form

Then I learned that a Code STEMI was activated for concern of anterior "STEMI" in V1-V2. 

The cath lab activation was appropriately cancelled by cardiology.

High sensitivity troponin I was 23 ng/L. Two more serial trops were each 23 ng/L.

He did not have OMI.

We think that Queen of Hearts may have the ability to reduce such false positive cath lab activations. We will study this soon.

Case 2

A man in his 60s presented with acute chest pain, about 1 hour prior to evaluation:

What do you think?

I texted back: "easy LAD OMI."

There are diagnostic hyperacute T waves in V2-V5, I, aVL, and II. There is 0.5 mm STE in V1, and 1.0 mm STE in V2. There is also 0.5-1.0 mm STE in aVL. In V3-V6, and II, III, aVF, the J point is depressed. Thus, leads V3-V5 and II are perfect de Winter morphology.

Also, if you use the LAD OMI formula: QT = 420, RAV4 = 5 mm, QRSV2 = 6 mm, STE60V3 = 2.5 mm, the value is 22.2 (LAD OMI!).  If the heart rate is under 60, do not correct the QT.  

Thus, this does NOT meet STEMI criteria (though, as of 2022, it is a formal "STEMI equivalent", assuming everyone agrees that this is de Winter morphology, for which there is currently no objective definition).

Smith: my non-objective (subjective) definition is "Hyperacute T-wave with a depressed ST takeoff"

He was taken immediately to the cath lab and found to have 100% thrombotic stenosis of the proximal LAD. He also had nonobstructive nonculprit RCA disease and normal LCX. 

Ventriculogram showed 35% EF with anteroapical akinesis.

After passing the wire through the occlusion.

After flow was restored.

ECG immediately post cath. T waves starting to become less hyperacute. No more ECGs are available, but they would hopefully show continued evolution of reperfusion.

The first troponin (high sensitivity troponin I) returned WITHIN NORMAL RANGE at 14 ng/L (normal up to 20 ng/L for men in this assay).

The second troponin was 17,962 ng/L, and none further were ordered.

Formal echo showed 40% EF, hypokinesis of anterior/anteroseptal/anteroapical walls. 

Final diagnosis: Anterior "STEMI"

Despite the fact that this patient never met STEMI criteria on any ECG, he is labelled as "STEMI" because he was treated like a "STEMI." He will be entered into the STEMI registry. His time from door to reperfusion will be carefully reviewed for any improvable delays. 

Often, I worry that the labels of "STEMI" and "NSTEMI" are simply applied retrospectively to correspond to which type of care was given (emergent vs. not emergent), rather than to correspond to the patient's actual initial ECG or actual pathology.

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Warning: Ignorable rant ahead, based only on anecdotes, etc.

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This case demonstrates another hypocritical lie that is imbedded in the STEMI paradigm:

Critics of OMI say that STEMI is helpful because it allows a prospective label that anyone can apply (wrong, of course, its interrater reliability is poor). 

Yet, at the same time they make this argument, they know that it is not actually applied prospectively in most cases, but rather retrospectively at the end of the patient's course, by the treating cardiologist. 

Although we say out loud and prospectively that STEMI criteria is what defines STEMI and decides whether a patient gets to go to the cath lab emergently, nobody actually even holds the physician accountable for correctly labelling the final diagnosis. 

If the ECG does not meet STEMI criteria, but the patient has an Occluded artery and terrible outcome, then (because there were no STEMI criteria and thus the patient did not get emergent reperfusion), the final diagnosis is almost always "NSTEMI," and so there are no consequences for inadequate management of acute coronary occlusion.

Even if a patient's ECG does meet STEMI criteria, it may not be perceived so.  In such a case, the interventionalist can simply give a final diagnosis of "NSTEMI" and it is not corrected (in my experience). 

Consequences for data: In both of these scenarios, the patient is entered as an NSTEMI into the NCDR database, and the time from door to reperfusion is not examined, doesn't count for the "STEMI" metrics, even if the patient dies of their delayed ACS treatment.

And in this case, we have the opposite mistake: Because this patient was correctly understood immediately to have acute coronary occlusion MI, and he was treated emergently, they decided to label him "STEMI", even though he by definition has NSTEMI.

Everywhere I'm aware of (only about 5 systems), the ECGs are not even recorded in the "STEMI database." So the singular piece of evidence that supposedly made the difference between whether the patient was STEMI or NSTEMI, the entire name of the MI paradigm, and dichotomy of the quality improvement database - we don't even keep a picture of it. 

I asked this for my STEMI database at my hospital, and the reaction was incredulous. No one has ever thought to save the ECG in the STEMI/NSTEMI database. Who would want that??? 

"How do you know if they were correctly entered as STEMI or NSTEMI, then?" I ask. 

"Well we just use the final diagnosis on the chart," they say.

What a farce. A definition based on measurements that nobody actually even measures, that doesn't actually correspond to the actual outcome, that is supposedly the prospective and retrospective definition of AMI but then can simply be disregarded when entering a final diagnosis - a final diagnosis that is the basis for all registries, studies, and clinical feedback, yet the information needed to adjudicate this diagnosis is not even recorded in the databases.